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      Optical coherence tomography guided thrombectomy through a “home-made” aspiration catheter in a young patient with myocardial infarction. To stent or not to stent?

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          Abstract

          Introduction Invasive coronary angiography (CA) is the traditional imaging modality for evaluation of the coronaries and guidance of percutaneous coronary intervention (PCI) during treatment of ST-segment elevation myocardial infarction (STEMI) [1]. However, CA provides just a two-dimensional luminography of the coronaries, without additional insights into plaque morphology, extent of atherosclerosis, thrombus burden and mechanisms of vessel occlusion [2]. The use of optical coherence tomography (OCT) delivers high-resolution images that accurately depict vessel and lesion characteristics, including the presence of thrombus, provides incremental assistance in stent implantation and minimizes stent-related issues [2]. OCT may also reveal the pathophysiology of arterial thrombosis, and optimize therapeutic options during PCI, especially in young patients where mechanisms of STEMI may vary [3]. Though plaque rupture remains the most common etiology of myocardial infarction (MI), in patients younger than 40–45 years unique syndromes such as plaque erosion, coronary microvascular dysfunction, spontaneous coronary artery dissection (SCAD), myocarditis, coronary embolism, hypercoagulable state and coronary spasm (drug related or not) are prevalent [3]. Consequently, intracoronary imaging is essential to clarify the underlying mechanisms when treating young MI patients, since stenting might not be the holy grail in this subgroup. Thrombus aspiration, though not routinely advocated by the guidelines, is required in selected patients for the recovery of coronary flow during primary PCI [1]. Previous reports have highlighted that in selected young patients presenting with STEMI, lone thrombus aspiration without balloon angioplasty or stenting is feasible and is associated with favorable short and long-term outcomes [4]. Dedicated thrombectomy catheters have been developed, but one size does not fit all anatomies, with some catheters being too small to accommodate a large thrombotic burden [5]. Aim We report the case of a young patient who presented with anterior STEMI and underwent thrombectomy of a large free-floating thrombus through a “home-made” aspiration device, assembled from a guiding extension catheter and a guide catheter. OCT showed no signs of plaque rupture, allowing deferral of stent implantation. Case report A 38-year-old man, with positive family history for coronary artery disease, presented with acute chest pain. Electrocardiography revealed hyperacute T waves in leads I, aVL, V2- > V6, corresponding with the diagnosis of an anterolateral STEMI (Figure 1 A). He was loaded with 250 mg of aspirin, 180 mg of ticagrelor and underwent emergency CA, via the right radial artery approach. CA revealed a subtotal occlusion of the proximal segment of the left anterior descending artery (LAD) with the presence of a mobile thrombus (Figure 1 B arrow) whereas the left main stem, circumflex and right coronary artery were normal. In view of the free-floating thrombus in the proximal segment of the LAD we decided to proceed with thrombus aspiration. After administration of 7500 IU of unfractionated heparin via a 6-French 3.5 extra back-up (EBU, Medtronic) guiding catheter, we tried to perform thrombosuction through a standard 6-French aspiration catheter, without success. We hypothesized that the small inner diameter (1.1 mm) of the standard aspiration catheter (Medtronic, Export) was not large enough to aspirate the large thrombus burden accumulated in the LAD. Figure 1 A – ECG showing anterolateral STEMI. B – Angiography revealed the presence of thrombus (arrow) in the proximal LAD. C – Guide extension catheter (arrow) through the guiding catheter at the proximal LAD Taking into consideration the large diameter of the vessel at the lesion site (between 3.5 and 4.00 mm), the proximal location of the thrombus and the large thrombus burden, we decided to construct a wider diameter “home-made” aspiration device by using a 6-French guiding extension catheter, which has an inner diameter of 1.45 mm and would theoretically offer a greater aspiration potential. Specifically, a 6-French Guidezilla II guide extension catheter (Boston Scientific) was advanced through the EBU guiding catheter at the proximal LAD (Figure 1 C, arrow). Successful thrombectomy was performed through the “guide extension-guiding catheter” assembly via a 20 cc luer-lock vacuum aspiration syringe attached to the manifold by a three-way stopcock (Figure 2 A). Prior to any further manipulation, vigorous back-bleeding through the Y-connector was performed, to eliminate any chance of air or thrombus embolism. Intracoronary injection of tirofiban followed, to ensure adequate resolution of thrombus microparticles, resulting in an excellent angiographic result (Figures 2 B, C). OCT illustrated normal lumen area with presence of minimal thrombus remnants (Figures 2 D, E, arrow), intima thickening and fibroatheroma (Figure 2 D, asterisk) without any signs of plaque rupture at the lesion site, allowing deferral of stent implantation. Control CA after 3 days revealed a perfect result. Figure 2 A – Guide extension-guiding catheter assembly: arrows indicate the luer-lock syringe attached to manifold, guidewire and guide extension catheter. B, C – Perfect angiographic result after thrombus aspiration. D, E – OCT illustrating presence of minimal thrombus remnants (D, E arrow), intima thickening and fibroatheroma (D, asterisk) without any signs of plaque rupture The patient was discharged in good condition with lifelong aspirin and ticagrelor for 1 year. At 3-month follow-up he was asymptomatic with a normal echocardiogram. Further investigation excluded paradoxical emboli but revealed a positive lupus anticoagulant, for which rheumatologists advised lifelong use of aspirin. Discussion Restoring coronary blood flow is of utmost importance in the treatment of STEMI during primary PCI. Impaired flow and decreased coronary perfusion is related to reperfusion injury, causing arrhythmias, suboptimal microvascular circulation, contractile abnormalities, permanent myocardial dysfunction and fatal events [6, 7]. Thrombus aspiration has been proposed as an adjunct to primary PCI to further improve epicardial and myocardial perfusion by the prevention of distal embolization of thrombotic material and plaque debris [1]. Despite the fact that thrombus aspiration can improve coronary blood flow and resolve ST-segment elevation, it is not routinely advocated by the guidelines (Class IIIA) [1]. The two landmark TASTE and TOTAL trials, which investigated the role of routine manual thrombus aspiration versus conventional PCI, showed no benefit in clinical outcomes of routine aspiration overall or in the high thrombotic risk subgroup [8–10]. Additionally, increased risk of stroke was noted in the TOTAL trial [9, 10]. Similarly, in a meta-analysis of 17 trials, aspiration thrombectomy was not shown to be of benefit in reducing the risk of death or reinfarction [11]. In the high-thrombus burden subgroup, the trend towards reduced cardiovascular death and increased stroke/transient ischemic attack (TIA) calls for further research and use of improved thrombus aspiration technologies in this high-risk subgroup [12]. However, in patients with heavy thrombotic burden, thrombus aspiration should be considered. Several randomized trials have demonstrated the effectiveness and safety of manual thrombus aspiration during primary PCI. The majority of studies in the literature conclude that thrombectomy improves TIMI flow and provides rapid resolution of ST segment deviation. The TAPAS and EXPIRA trials, along with a few meta-analyses, reported that thrombectomy improves the long-term clinical outcome of reducing cardiac death and major adverse cardiovascular events (MACE). However, these studies showed no statistical significance for the prediction of MACE [13, 14]. The EXPIRA trial illustrated a reduction of the infarct area in cardiac magnetic resonance imaging, after thrombectomy [14]. A survival benefit among patients with STEMI was suggested by the TAPAS trial [13]. In addition, STEMI is an uncommon entity in young adults and its incidence depends on the cut-off age used [15]. Most studies have used an age cut-off of 40–45 years to define young patients with STEMI [3]. It has been reported that < 1% of patients with STEMI are ≤ 35 years [15]. Young STEMI patients differ from older patients in the risk factor profile and in the extent of atheromatic plaque coronary burden. In particular, young coronary patients are characterized by a higher proportion of heavy smoking, a lower proportion of hypertension and diabetes mellitus and a relatively high proportion (15–20%) of angiographically “normal” coronary arteries [15]. Apart from the classical mechanism of plaque rupture, MI in young individuals can be attributed to plaque erosion, coronary microvascular dysfunction, SCAD, myocarditis, coronary embolism, hypercoagulable state and coronary spasm related or not to drug use (e.g. cocaine) [3]. In particular, the presence of antiphospholipid antibodies, such as the positive lupus anticoagulant detected in our patient, is a known risk factor for arterial and vein thrombosis by causing a hypercoagulable state [3]. Therefore, diverse underlying mechanisms may be present in young patients with MI, requiring tailored interventional and drug therapy. The use of OCT is essential to reveal the underlying pathophysiology, and optimize therapeutic options [2]. In our patient OCT showed no signs of plaque rupture, allowing deferral of stent implantation after adequate thrombus aspiration. From a practical point of view, coronary diameter varies between individuals, and commercially available thrombectomy catheters may not be suitable for certain anatomies to achieve sufficient thrombus aspiration (Table I A). Guiding extension catheters have a larger inner diameter and can offer a greater aspiration potential (Table I B). The assembly and use of a home-made aspiration catheter has already been described above. Of note, this technique should only be used if the coronary artery is large enough to accommodate the assembly, since the guide extension catheter can dissect the coronaries and only when the guiding catheter has perfectly engaged the coronary artery to avoid dislocation of thrombus to the systematic circulation during manipulations. Table I Characteristics of commonly used thrombus aspiration (A) and guide extension catheters (B) A. Thrombus aspiration catheters (size 6 Fr) Manufacturer Device trade name Catheter length [cm] Aspiration lumen area/diameter [mm2/mm] Vascular Solutions Pronto V3 140 0.93/1.09 Medtronic Export AP 140 1.08/1.17 Diver CE 145 1.01/1.14 Boston Scientific Fetch 2 135 0.79/1.00 Terumo Eliminate 140 0.79/1.00 Priority One 140 0.85/1.04 Merit Medical ASAP AC Kit 140 1.24/1.26 Meril Aspiron 140 0.69/0.94 Stentys Stentys AC 145 0.95/1.10 B. Guide extension catheters (size 6 Fr) Boston Scientific Guidezilla 145 1.65/1.45 Guidezilla II 150 1.65/1.45 Vascular Solutions GuideLiner 150 1.58/1.42 IMDS Guidion 150 1.58/1.42 Boosting Catheter QX Medical 150 1.65/1.45 Teleflex Trapliner 150 1.58/1.42 Conclusions Diverse underlying mechanisms may be present in young patients with MI, requiring a case-by-case approach. The use of intracoronary imaging is essential to elucidate the diagnosis and optimize therapeutic options. In selected young patients with MI, OCT-guided lone thrombus aspiration without balloon angioplasty or stenting, either by conventional means or home-made aspiration catheters, can be a feasible and effective therapeutic approach.

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          Most cited references15

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          Cardiac death and reinfarction after 1 year in the Thrombus Aspiration during Percutaneous coronary intervention in Acute myocardial infarction Study (TAPAS): a 1-year follow-up study.

          Percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction can be complicated by spontaneous or angioplasty-induced embolisation of atherothrombotic material. Distal blockage induces microvascular obstruction and can result in less than optimum reperfusion of viable myocardium. The Thrombus Aspiration during Percutaneous coronary intervention in Acute myocardial infarction Study (TAPAS) found that thrombus aspiration resulted in improved myocardial reperfusion compared with conventional PCI, but whether this benefit improves clinical outcome is unknown. We aimed to investigate whether the early efficacy of thrombus aspiration seen in TAPAS translated into clinical benefit after 1 year. Patients with ST-elevation myocardial infarction enrolled at the University Medical Centre Groningen were randomly assigned in a 1:1 ratio to either thrombus aspiration or conventional treatment, before undergoing initial coronary angiography. Exclusion criteria were rescue PCI after thrombolysis and known existence of a concomitant disease with life expectancy less than 6 months. Of the 1071 patients enrolled between January, 2005, and December, 2006, vital status at or beyond 1 year after randomisation was available for 1060 (99%). The primary endpoint was cardiac death or non-fatal reinfarction after 1 year, and analysis was by intention to treat. The TAPAS trial is registered with Current Controlled Trials number ISRCTN16716833. Cardiac death at 1 year was 3.6% (19 of 535 patients) in the thrombus aspiration group and 6.7% (36 of 536) in the conventional PCI group (hazard ratio [HR] 1.93; 95% CI 1.11-3.37; p=0.020). 1-year cardiac death or non-fatal reinfarction occurred in 5.6% (30 of 535) of patients in the thrombus aspiration group and 9.9% (53 of 536) of patients in the conventional PCI group (HR 1.81; 95% CI 1.16-2.84; p=0.009). Compared with conventional PCI, thrombus aspiration before stenting of the infarcted artery seems to improve the 1-year clinical outcome after PCI for ST-elevation myocardial infarction.
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            Outcomes 1 year after thrombus aspiration for myocardial infarction.

            Routine intracoronary thrombus aspiration before primary percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI) has not been proved to reduce short-term mortality. We evaluated clinical outcomes at 1 year after thrombus aspiration.
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              Acute Myocardial Infarction in Young Individuals

              Globally, cardiovascular disease remains a major cause of adverse outcomes in young individuals, unlike its decline in other age groups. This group is not well studied and has a unique risk profile with less traditional cardiovascular risk factors compared with older populations. Plaque rupture still remains the most common etiology of myocardial infarction, but unique syndromes such as plaque erosion, coronary microvascular dysfunction, spontaneous coronary artery dissection, and coronary spasm related to drug use are more prevalent in this age group. Such diversity of diagnosis and presentation, along with therapeutic implications, underscore the need to study the profile of myocardial infarction in young persons. We searched PubMed for articles published from 1980 to 218 using the terms acute myocardial infarction, young, plaque rupture, plaque erosion, spontaneous coronary artery dissection (SCAD), coronary vasospasm, variant or Prinzmetal angina, drug-induced myocardial infarction, myocarditis, coronary embolism, microvascular dysfunction, MINOCA, and myocardial infarction in pregnancy and reviewed all the published studies. With the data from this search, we aim to inform readers of the prevalence, risk factors, presentation, and management of acute myocardial infarction in young patients and elaborate on special subgroups with diagnostic and therapeutic challenges. We also outline a parsimonious method designed to simplify management of these complex patients.
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                Author and article information

                Journal
                Postepy Kardiol Interwencyjnej
                Postepy Kardiol Interwencyjnej
                PWKI
                Postępy w Kardiologii Interwencyjnej = Advances in Interventional Cardiology
                Termedia Publishing House
                1734-9338
                1897-4295
                29 December 2020
                December 2020
                : 16
                : 4
                : 486-490
                Affiliations
                [1 ]Department of Cardiology, Catharina Ziekenhuis Eindhoven, the Netherlands
                [2 ]Department of Cardiology, Asklepeion General Hospital, Athens, Greece
                [3 ]Department of Cardiology, Medisch Centrum Leeuwarden, the Netherlands
                Author notes
                Corresponding author: Andreas S. Triantafyllis MD, PhD, Catharina Ziekenhuis Eindhoven, the Netherlands, e-mail: andtridoc@ 123456yahoo.gr
                Article
                42713
                10.5114/aic.2020.101777
                7863833
                33598025
                23d034c8-e315-49b7-9ef3-824fbd2bfd92
                Copyright © 2020 Termedia Sp. z o. o.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International (CC BY-NC-SA 4.0). License ( http://creativecommons.org/licenses/by-nc-sa/4.0/)

                History
                : 24 August 2020
                : 15 October 2020
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